John K. Lattimer

Carcinoma of the prostate: treatment with external radiotherapy

In recent years external radiotherapy has been selected as primary treatment of patients with carcinoma of the prostate localized to the pelvis. Among 146 patients treated with external radiotherapy at Columbia‐Presbyterian Medical Center, the 5 and 10 year survival rates were 64.1% and 40.5%, respectively. The 5‐year survival rate was 88.2% for patients with Stage A, 86.8% for Stage B and 58% for Stage C; it was 64.4% for patients with more differentiated carcinomas, but only 28.7% for patients with undifferentiated tumors. Patients with obstructive changes on IVP had a 5 year survival rate of 24.1%, whereas, for patients with no obstruction on IVP, this rate was 71.3%. When radiotherapy started within 6 months after the diagnosis, the 5 year survival rate was 70.3%, whereas, a delay in starting radiotherapy, for more than 6 months after the diagnosis, was associated with a survival rate of 31.9%. Radiation dose of 6500 rad or more was associated with a 5‐year survival rate of 86.7%, whereas, for a dose of less than 6500 rad this survival rate was 57.1%. All the above differences were statistically significant (p < 0.05). Other factors that were examined and were found to influence the prognosis to a degree that was not statistically significant included: age of the patient at the time of radiotherapy, presenting symptoms, levels of acid phosphatase in the serum and in the bone marrow and size of the irradiated volume. In agreement with other published series the complications were usually mild and their incidence low. Tumor involving and protruding into the urethra may have contributed to the formation of urethral strictures. Local control of this cancer with external radiotherapy appears very successful. Treatment failures were manifested most often with distant metastases with or without local recurrence, suggesting that subclinical distant metastases might have been present prior to initiation of radiotherapy. External radiotherapy rather than brachyterhapy, appears to be the treatment of choice for cancer of the prostate with indications for radiotherapy.

Long-term followup of 207 patients with bladder exstrophy: an evolution in treatment.

Between 1945 and 1985 a total of 207 patients (male-to-female ratio 2:1) was treated at our institution for exstrophy of the bladder. Primary anatomical bladder closure was performed in 137 patients, of whom 42 (31 per cent) eventually required urinary diversion. Primary urinary diversion was the initial treatment in 70 patients, including ureterosigmoidostomy in 40, ileal conduit in 17, colon conduit in 11 and cutaneous ureterostomy in 2. Secondary urinary diversion was necessary in 35 patients and included continent diversion in 7. Primary anatomical bladder closure, done within 72 hours of birth and followed by staged reconstruction of the bladder neck, was the most successful surgical regimen for the treatment of bladder exstrophy. Acceptable urinary continence was achieved in 82 per cent of our patients with this approach. However, multiple procedures often were required to achieve continence.

Prune Belly Syndrome: 35 Years of Experience

Between 1949 and 1984, 50 children with the prune belly syndrome were treated at our institution. The modes of evaluation and treatment, and the long-term results are discussed.

FOREIGN BODIES IN URINARY BLADDER

Abstract Ten patients with foreign bodies in the bladder are herein reported from the urologic admissions of the Squier Clinic at Columbia Presbyterian Medical Center. Twelve foreign bodies were removed from these 10 patients. They consisted of three glass stirring rods, two hairpins, two umbilical tapes, one ball-point pen, one pencil, one rubber tube, one Penrose drain, and one bougie. Seven of these objects were self-introduced; the Penrose drain was left in the bladder during a previous suprapubic prostatectomy, and the two umbilical tapes used in previous gynecologic surgery had worked their way into the bladder. The clinical features, diagnostic maneuvers, and methods of treatment have been described, and the literature on foreign bodies reviewed.

Interaction of ultrasound with neoplastic tissue. Local effect on subcutaneously implanted Furth-Columbia rat Wilms' tumor.

Ultrasonic irradiation was employed by direct administration to the skin overlying subcutaneously implanted Furth-Columbia rat Wilms tumors. Treated tumors were flattened and excavated and demonstrated no stigmata of hemorrhage or infection. There was a marked decrease in growth rate of the tumors with an increase in survival time of the host. Histologic assessment with the light microscope exhibited a sharp line of demarcation between the necrosed sonicated portion of tumor and the viable intact nonsonicated area of tumor. A blackened area of skin, which was not histologically similar to a burn, was interposed betwwen the site of application of the ultrasound and the necrosed tumor.

The Exstrophy Support Team: A New Concept in the Care of the Exstrophy Patient

The concept of the exstrophy support team is reported. It has extended the care of children with exstrophy into a lifelong continuum of effective assistence, not just by way of medical and surgical interaction but through knowledgeable and sympathetic coordination. There has been a spectacular improvement in over-all lifetime survival and much greater patient interest and appreciation with better followup and maintenance so that we can help quickly and effectively when problems arise. Now that we have achieved an increased longevity for these patients, we must be able to assure them the best possible quality of life.

An Evaluation of the Current Therapeutic Regimen for Renal Tuberculosis

Renal tuberculosis will continue to be a potentially lethal disease and must be considered a diagnostic possibility in all patients with infection in order to discover it in time. Multiple drug regimens have withstood the test of time and it appears that triple drug therapy is more efficacious than 2 drugs since triple drugs permit the skipping of 1 or another of the medications with less danger of relapse. Rifampin is a new drug that is well tolerated and efficacious, although expensive. We recommend continuous use of triple drugs for 2 years at least with the continuance of pyridoxine. We advise an excretory urogram, the collection of 3 urine specimens for culture and the passage of ureteral catheters every 6 months during treatment and every 12 months thereafter for 10 years. We do not consider relapse an indication for an operation but for further therapy, using medications to which the patients organism is proved susceptible by bacteriologic means. Under modern conditions an operation is rarely necessary.

Common stomal problems following ileal conduit urinary diversion: Recognition and treatment*

Abstract Stomal complications following ileal conduit urinary diversion continue to be reported unduly high numbers. Some of the complications in the immediate postoperative period could be prevented by increased awareness of the importance of the type and location of the stomal bud and management of the collection device. Over the long-term, close follow-up to insure that the appliances fit properly, are kept meticulously clean, and that an acid urine is maintained will obviate any of the distressing sequelae associated with the ureteroileocutaneous anastomosis. Recognition the most common problems and suggestions for simple conservative treatment are offered.

Tissue expansion of underdeveloped scrotum to accommodate large testicular prosthesis: A technique

A contracted empty scrotum in a young man will not accept an artificial testis satisfactorily using any of the standard techniques. Previous operative scars, as from a failed orchiopexy, have often added to the difficulties. Greatly enlarging the scrotum by gradual distention of a tissue expander implanted in the contracted side has been successful in overcoming this problem, both cosmetically and functionally.

A new dimension in the diagnosis of posterior urethral valves in children.

Infants with posterior urethral valves may seem to have diverse and unrelated symptoms when, in fact, the clinical findings are all related to the primary effect of the valves during various stages of early growth. In some, prenatal urinary obstruction leads to such severe oligohydramnios that the fetus is stillborn. Others, somewhat less affected, are born alive but have severe respiratory distress from hypoplastic (stiff) lungs and die of respiratory problems. Still others can be associated with massive ascites and urinomas, and be stillborn or die soon after birth. In less severe cases the neonates may have unexplained respiratory distress with pneumomediastinum or pneumothorax as the only indication of obstructive urologic disease with deficient urinary output. Urinomas or ascites may later develop beyond the neonatal period as the post-natal obstructive effects of the valves accumulate and the urinary system ruptures and decompresses itself. Finally when the urinary system does not decompress itself, the back pressure can lead to rapid and progressive renal damage until the kidneys can no longer concentrate urine and lose water. The infant becomes dry, acidotic and paradoxically at this stage, puts out large quantities of dilute urine. Physicians caring for infants should be highly suspicious of posterior urethral valves in any male infant with unexplained respiratory distress or metabolic derangements, abdominal distension or flank masses.